Provider Demographics
NPI:1376564823
Name:LANE, LAWRENCE BENJAMIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:BENJAMIN
Last Name:LANE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 MICHAELS RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-5506
Mailing Address - Country:US
Mailing Address - Phone:423-753-5735
Mailing Address - Fax:
Practice Address - Street 1:CORNER OF SIDNEY AND LAMONT (JOHNSON CITY)
Practice Address - Street 2:JAMES H. QUILLEN/VAMC
Practice Address - City:MOUNTAIN HOME
Practice Address - State:TN
Practice Address - Zip Code:37684
Practice Address - Country:US
Practice Address - Phone:423-926-1171
Practice Address - Fax:423-979-3428
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4645122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist